"Suppose you're thinking about a plate of shrimp. Suddenly someone will say 'plate' or 'shrimp' or 'plate of shrimp,' out of the blue. No explanation and there's no point in looking for one either. It's all part of the cosmic unconsciousness."
Tracey Walter as "Miller" in "Repo Man"

Tuesday, March 10, 2009

Twenty Minutes

Dani walked up the hallway to the desk and told me that the patient in room 10 wanted to leave "against medical advice."

"You mean the chest pain guy with the GI bleed?" I asked.

"Yes," she said, "He doesn't want the tests."

"But his cardiolyte [stress test] was positive and he's got an active bleed," I said.

"Maybe you could talk to him, shrimplate," said Dani, but I had a feeling it was a lost cause. The patient was a little belligerent when he came up yesterday. All he did was complain.

For example, he said that he wanted to eat but refused his insulin because his blood sugar was only 290 and that "wasn't high for him." And he was using 70/30 insulin at home on some kind of weird sliding-scale, the way people use Novolog or regular insulin. The doctors here had ordered a regular insulin sliding scale but the patient wouldn't have anything to do with that. He said that it would "kill him."

I had talked to him then and figured out at least what he did at home; though I didn't agree with it, it made sense to him and we managed to get that one issue temporarily out of the way.

Today, he wanted to go home because he was "all through with us." Hmmmm....

Abnormal stress test.Bloody stool.Poorly controlled diabetes.

Sounded to me like he was just beginning: A long, slow, expensive spiral into further hospitalizations, heart failure, renal failure, and eventually a miserable death.

I explained that the cardiologist wanted to do a catheterization to fix the clogged blood vessels in his heart, but we wanted to first make sure he wasn't losing blood from an ulcer in his digestive tract.

See how simple that is? Just one little sentence. Does that make any sense to you? It does to me. I couldn't make it any plainer than that. We'd have him patched up and in a day or two he'd be just like new. New for him anyway, whatever that's worth.

The patient scoffed and said that I was talking down to him. "I didn't get to be 68 years old without knowing what's going on with me," he coughed out.

"So then, what do you think is going on with your heart?" I asked, and that set him off even though I was using a polite tone of voice.

"Nothing!" he barked, pulling on his pants. He was dressing himself in street clothes as we had our little chat. He added that further testing would just stress him out and his body couldn't take that. As if internal bleeding and cardiac ischemia provided his body with pleasant rest and relaxation. Oh well. That gave me what I needed to chart on him leaving AMA.

Then the GI resident came in; she asked me to leave so that she could talk with him. I said that I just wanted to ensure that the patient was making an "informed decision," and she asked me to leave again. I went to get the against-medical-advice form for him to sign.

I returned and set the paper on the bedside table between them. He looked up and said "what's this?" and I just replied "It's for you." The resident said that I could finish talking with him in a moment and I said that I was all done.

He left twenty minutes later.

That was yesterday. Chances are pretty good that he's had recurrent chest pain since then. It doesn't go away untreated. It just eventually gets worse. He's probably in another hospital. Maybe right now, as I write, he's pulling on his pants again.